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BLOOD & BODY
FLUID
EXPOSURE
MANAGEMENT
Revised April 2013
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Table of Contents
Chapter 1
Introduction………………………………………………………………………………………………..1
YCDC Role in Post Exposure Management…………………………………………………………...1
Consultation with BC Centre for Excellence…………………………………………………………...1
Consultation Regarding Post Exposure Management………………………………………………..2
Contact Information………………………………………………………………………………………3
Where to Access Care…………………………………………………………………………………...4
Chapter 2
Indications for Post Exposure Management…………………………………………………………...5
Steps Following Exposure to Blood or Body Fluid…………………………………………………….6
Cleanse……………………………………………………………………………………………6
Triage……………………………………………………………………………………………...6
Risk of Exposure Assessment (Exposed Person)……………………………………………7
Blood and Body Fluid Exposure Management Algorithm……………………………………8
Risk of Transmission Assessment (Source Person)…………………………………………9
Determining the Status of the Exposed Person……………………………………………..10
Counsel………………………………………………………………………………………….10
Clinical and Laboratory Follow-Up……………………………………………………………11
Follow-Up Testing………………………………………………………………………………12
Testing of the Exposed Person (Table 1)……………………………………………………13
Laboratory Collection of Specimens (Table 2)………………………………………………14
Record…………………………………………………………………………………………...14
Follow-Up of Exposed Person and Source Person…………………………………………15
Table of Contents
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Chapter 3
Stratification of HIV Exposures (Table 3)……………………………………………………………..16
Antiretroviral Therapy…………………………………………………………………………………...17
Contraindications to Antiretroviral Therapy…………………………………………………………..17
Antiretroviral Starter Kit…………………………………………………………………………………18
Availability of Antiretroviral Kits………………………………………………………………………..19
Chapter 4
HBV Exposure…………………………………………………………………………………………...20
Hepatitis B Post-Exposure Prophylaxis (Table 4)……………………………………………………21
How to Access HBIG……………………………………………………………………………………22
Chapter 5
HCV Exposure…………………………………………………………………………………………..23
Table of Contents
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
APPENDIX
A
Fluids and Tissues Capable of Transmitting Bloodborne Pathogens………………………...24
B
Risk Factors for Possible Transmission…………………………………………………………25
C
Window Periods……………………………………………………………………………………26
D
Post Exposure HIV Antiretroviral Therapy in Children………………………………………...27
E
Post Exposure HIV Antiretroviral Therapy in Pregnant Women……………………………...28
F
Considerations Pertaining to Breast Feeding…………………………………………………..29
G
Male and Female Sexual Assault HIV Risk/Post Exposure Prophylaxis……………………30
H
BCCDC PHSA Laboratory Serology Requisition………………………………………………31
I
BCCDC PHSA Laboratory Virology Requisition………………………………………………..32
J
Blood and Body Fluid Exposure Form………………………………………………………33-34
K
Exposed Person’s Follow-Up Plan………………………………………………………………35
L
Blood and Body Fluid Exposure Counselling Guideline……………………………………….36
M
Reducing Transmission to Others……………………………………………………………….37
N
Probability of Transmission of HIV, HBV and HCV…………………………………………….38
O
Counselling Guidelines for HIV Antiretroviral Therapy…………………………………….39-40
P
Medication Information Sheet: Lopinavir/Ritonavir (Kaletra)……………………………...41-42
Q
Medication Information Sheet: Lamivudine (3TC)……………………………………………..43
R
Medication Information Sheet: Tenofovir (VIREAD)…………………………………………...44
Table of Contents
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
INTRODUCTION AND CONTACT INFORMATION
Introduction
•
These guidelines outline the risk assessment and management for potential
percutaneous, mucosal, or non-intact skin exposures to human immunodeficiency
virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) from blood or body
fluids.
•
This manual is intended for Emergency Department Staff, Community Health Nurses,
Nurse Practitioners, Physicians, Infection Control Practitioners, Occupational Health
Practitioners and Infectious Disease Nurses.
Yukon Communicable Disease Control (YCDC) Role in Post Exposure
Management
•
YCDC provides consultation services to health care professionals when questions
arise on post exposure management during hours of operation.
•
Individuals exposed to blood and/or body fluids can be referred to YCDC for
management during hours of operation.
(Refer to pg. 3 for YCDC contact information and hours of operation)
Yukon Consultation with BC Centre for Excellence in HIV/AIDS
•
The BC Centre for Excellence in HIV/AIDS (BC-CfE) has an agreement with the
Yukon to provide consultation services for managing cases of accidental exposure or
risk of exposure to HIV.
•
The BC-CfE service is available to Yukon physicians and nurses working in
Community Health Centres, who request consultation regarding case management of
an exposed person to HIV or risk of HIV exposure.
•
This support is offered via telephone consultation with an on-call BC-CfE pharmacist
with expertise in this specialized field.
•
Community Nurses – When using BC-CfE consultation service, please be advised
that should HIV post exposure prophylaxis be recommended, this should be
discussed and prescribed by a licensed Yukon Physician.
•
The program also allows Yukon Health Professionals access to BC-CfE
guidelines. Including: “Management of Accidental Exposure to HIV” guideline
which can be found online at: http://www.cfenet.ubc.ca/therapeutic-guidelines
(Refer to pg. 3 for BC-CfE contact information)
Chapter 1: Introduction and Contact Information
1
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
For Questions Regarding Post Exposure Management
Contact YCDC - Monday – Friday 0830 to 1630hrs
Yukon Registered Nurses
When calling YCDC for consultation please indicate that your call is regarding post
exposure management.
After Hours/Weekends
1. Whitehorse General Hospital - Emergency Department Physician on call or the
Community Physician.
2. The Medical Officer of Health may be called if required after calling the WGH ER
Physician or Community Physician.
3. *BC-CfE may be called by the RN if requested by the physician, MOH and
in the situation of a complex case, i.e. exposure occurred in a pregnant woman.
*Community Nurses – When using BC-CfE consultation service, please be advised that
should HIV post exposure prophylaxis be recommended, this should be discussed
and prescribed by a licensed Yukon Physician.
Yukon Physicians
Contact any of the following (depending on the nature of the inquiry):
•
•
•
Yukon Communicable Disease Control
Dr. Brendan Hanley MOH
BC Centre for Excellence in HIV/AIDS
Chapter 1: Introduction and Contact Information
2
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Contact Information
Yukon Communicable Disease Control
Hours: Monday- Friday (0830-1630)
#4 Hospital Road,
Whitehorse, Yukon
Y1A 3H8
Telephone
Local (867) 667-8323
Within Yukon 1-800-661-0408 ext: 8323
Fax (867) 667-8349
Whitehorse General Hospital
Emergency Department
(Ambulatory Care)
#5 Hospital Road,
Whitehorse, Yukon
Y1A 3H7
Tel: (867) 393-8700
Fax: (867)393-8707
Dr. Brendan E. Hanley MD CCFP (EM) MPH
Chief Medical Officer of Health, Yukon
#4 Hospital Road,
Whitehorse, Yukon
Y1A 3H8
Tel: (867) 456-6136
Fax: (867) 667-8349
Cell: (867) 332-1160
BC Centre for Excellence in HIV/AIDS
608-1081 Burrard St.
Vancouver, BC V6Z 1Y6
Monday – Friday (0800 – 1700) Tel: (604) 806-8429
Afterhours and weekends Tel: (604) 341-1410
Fax: (604) 806-9044
Website: www.cfenet.ubc.ca
Chapter 1: Introduction and Contact Information
3
Blood and Body Fluid Exposure Management
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Accessing Care in the Yukon for Post Exposure Management
(Exposed Person)
Whitehorse General Hospital
Employees
• The exposed employee should report to the WGH Infection Control/
Occupational Health Practitioner or designate.
•
After hours and weekends the exposed employee should be assessed by
a physician in the Emergency Department.
In-Patient
• The attending physician or Nurse in Charge should contact the WGH Infection
Control/ Occupational Health Practitioner or designate. For after hours and
weekends the attending physician or Nurse in Charge will be responsible for the
assessment and initial management.
Infection Control and Occupational Health Practitioner
Whitehorse General Hospital
Hours: Monday-Friday
Tel: (867) 393-8933
Fax: (867) 393-8943
Whitehorse General Public
•
The exposed Whitehorse community member can be referred to the following
location
Yukon Communicable Disease Control
Whitehorse General Hospital
#4 Hospital Road
Emergency Department
Whitehorse, Yukon, Y1A 3H8
(Ambulatory Care)
Hours: Monday- Friday (0830-1630)
#5 Hospital Road
Tel: (867)667-8323
Whitehorse, Yukon, Y1A 3H7
Fax: (867)667-8349
Tel: (876) 393-8700
Fax: (867)393-8707
Communities Surrounding Whitehorse
•
The exposed community member should go to the Community Health
Centre to be assessed by a Community Health Nurse or physician.
Chapter 1: Introduction and Contact Information
4
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
POST EXPOSURE MANAGEMENT
Indications for Post Exposure Management
Post-exposure management is required when all of the following
4 indications are present:
•
•
•
•
percutaneous, mucosal or non-intact skin (i.e. presence
of wound/s, dermatitis) exposure;
the exposure is to blood, potentially infectious body fluid
or tissue (see Appendix A: Fluids and Tissues Capable of
Transmitting Bloodborne Pathogens);
the source is considered potentially infectious (positive test,
or in a higher risk group, or exposure occurred in a higher
risk setting);
AND
the exposed person is considered susceptible to at least one
of the following viruses:
•
•
•
Chapter.2: Post Exposure Management
HIV,
HBV, or
HCV
5
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Important Steps Following Exposure to Blood or Body Fluid
1. Cleanse the Exposed Area
•
•
•
•
•
Mucous membrane or eye: rinse well with water and/or normal saline.
Skin: wash well with soap and water.
Allow injury/wound site to bleed freely, and then cover lightly.
Do not promote bleeding of percutaneous injuries by cutting,
scratching, squeezing, or puncturing the skin. This may damage the
tissues and increase uptake of any pathogen(s).
Do not apply bleach to the injury/wound or soak it in bleach.
2. Triage Points for Consideration
If percutaneous, mucosal, or non-intact skin exposure has occurred, the exposed
person should have a risk assessment performed by a qualified health professional,
preferably within 2 hours of exposure.
Hepatitis B
•
•
•
If indicated, Hepatitis B immune globulin (HBlg) should be given as soon
as possible and preferably within 48 hours following the exposure.
If indicated, following a percutaneous exposure, HBlg should be received no
later than 7 days following the exposure.
If indicated, following a mucosal or sexual exposure, HBlg should be received
no later than 14 days following the exposure.
HIV Antiretroviral Therapy
•
•
If antiretroviral therapy is indicated, it should be initiated as soon as possible
after exposure, preferably within 2 hours.
There is no absolute cut-off time for the initiation of antiretroviral therapy for
“significant risk” exposures (see Table 3, pg. 16 for description of these types
of exposures).
Chapter 2: Post Exposure Management
6
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
3. How to Assess the Risk of Exposure
•
•
Complete a risk assessment using the Blood and Body Fluid Exposure Form
(BBFE). The form is designed as an information management tool to facilitate
the collection of exposure information and recording of post-exposure treatment
and management.
Refer to Appendix J, Blood and Body Fluid Exposure Form
•
•
All practitioners can access the form electronically at
http://www.hss.gov.yk.ca/exposure_management.php
It is also located in Section 16, of the Yukon Immunization Program
Manual
What is the Risk of Transmission from the Exposure?
The following body substances have not been implicated in the transmission of HIV,
HBV, or HCV unless they contain visible blood: (Refer to Appendix A, Fluids and
Tissues Capable of Transmitting Bloodborne Pathogens).
•
•
•
•
•
•
•
faeces
nasal secretions
sputum
sweat
tears
urine
vomitus
Refer to Appendix N, Probability of Transmission of HIV, HBV, HCV
Chapter 2: Post Exposure Management
7
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Blood and Body Fluid Exposure Management Algorithm:
Exposed Person
Are the four indications present for post-exposure
management?
• percutaneous, mucosal or non-intact skin
• exposure to blood or infectious body fluids
• potentially infectious source
• susceptible exposed person
No
Yes
• Assess risk of the source for HIV,
HBV and HCV
Refer to Appendix B: Risk Factors for
Possible Transmission
HIV
Obtain baseline
anti – HIV
• Assess eligibility
for PEP
Refer to Table 3,
pg 16: Stratification
of HIV Exposure
Significant risk:
Start PEP:
Refer to Table 1,
pg 13:Testing of the
Exposed Person
• No post exposure management required
• Provide education, counseling or advice
as appropriate
HCV
HBV
• Complete baseline
serology
• Determine HBV
susceptibility
Refer to Table 4, pg 21:
Hepatitis B PostExposure prophylaxis
• Complete baseline Anti- HCV serology
• Note: There is no initial PEP for HCV
Source
Unknown
Source
Known
Complete 3
and 6 month,
serology
(Anti HCV)
Negligible Risk:
No PEP
Complete:
3, 6 week and 3, 6
month serology
*Antiretrovirals are not recommended for needlesticks from an
abandoned needle in a community setting when there is no
history of the origin of the needle or the time of its abandonment.
Chapter 2: Post Exposure Management
Source
HCV -ve
Complete 3
and 6 month
Serology
(Anti HCV)
Negative:
Complete 3 and 6
month serology
(Anti HCV)
Source
HCV +ve
or High
Risk
Complete 3
week HCV
RT-PCR
Positive:
Repeat PCR test to
confirm result on a
separate specimen
If positive, active infection is
confirmed - consult with YCDC about
monitoring and treatment options
8
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
4. Assess the Risk of Transmission from the Source
• Determine if the source identity of the blood or body fluid is known. If source is
known, attempts should be made to have the source tested as soon as possible.
• For consideration of window periods – HIV, HBV, HCV, Refer to Appendix C.
• The source should be managed by someone OTHER THAN the exposed individual.
• Obtain the source person’s consent for testing for (Refer to Table 2, pg 14: Lab
Collection of Specimens).
• Anti-HIV
• Anti-HCV
• HBsAG
• Anti-HBs
• Anti-HBc
• The appropriate pre- and post-test counselling should be done for each test.
Obtaining informed consent from the source is an integral part of all post-exposure
testing procedures, as is maintaining confidentiality of all information.
Discuss the following with the source person:
•
•
•
Why/how their test results are needed for the management of the exposed person, as
well as the importance for follow-up of their own test results.
Their consent is needed for:
• Disclosure of their test results to their Health Care Provider (so they can be
contacted with the results).
• Disclosure of their test results to the exposed person’s Health Care
Provider.
• Test results to be sent to Yukon Communicable Disease Control.
That the exposed person will not be informed of their (the source) test results, nor
their identity, if not already known.
Inform the source that:
•
For all positive results, a lab report will be sent to the submitting Health Care Provider
and to Yukon Communicable Disease Control.
If the source refuses testing, carefully consider the reasons for refusal. If there is no reason
to suspect the source is in a high-risk group for HIV, HBV, HCV and refusal is based on
factors other than fear of disclosure, then consider this a low risk source. It is not appropriate
to automatically consider persons who refuse testing to be at high risk of infection.
Please note: A mandatory testing and disclosure act (of source) is not currently in
place in the Yukon.
Counsel
• Provide counselling in the health facility as required, with more detailed counselling to
be provided by the follow up health care provider.
Chapter 2: Post Exposure Management
9
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
5. Determine the HIV, HBV and HCV Status of the Exposed Person
Do not wait for test results before commencing post-exposure treatment
•
•
Determine the status of the exposed person with respect to prior infection with
HIV, HCV or HBV and previous immunization against HBV.
Obtain the exposed person’s consent and collect samples for the appropriate
tests (Refer to Table 1, pg 13: Testing of the Exposed Person, Table 2, pg. 14:
Laboratory Collection of Specimens).
• anti-HIV
• anti-HCV
• HBsAG
• anti-HBs
• anti-HBc
•
This baseline testing is critical for occupational exposures and possible
compensation by the Worker’s Compensation Board (WCB) – please refer to
facility specific information regarding WCB claims as this is not discussed further
in this guideline.
•
Obtain and document consent from the exposed person for disclosure of lab
results to their:
• Follow-up Health Care Provider
• Yukon Communicable Disease Control
•
The appropriate pre- and post-test counselling should be done for each test.
Obtaining informed consent from the source is an integral part of all
post-exposure testing procedures, as is maintaining confidentiality of all
information.
Inform the exposed person that:
•
For all positive results, a lab report will be sent to the submitting Health
Care Provider and to YCDC.
6. Counsel
•
Provide post-exposure counselling in the health facility, with more detailed
counselling to be provided by the follow up health care provider or
by Yukon Communicable Disease Control in a follow up visit.
•
Counseling should include points in Appendix L “Blood and
Body Fluid Exposure Counseling Guidelines”,
Appendix M “Reducing
Transmission to Others” and Appendix N “Probability of Transmission of HIV, HBV
and HCV”.
Chapter 2: Post Exposure Management
10
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
7. Arrange Clinical and Laboratory Follow-Up
If possible, draw the required initial blood work of the exposed person and source
while they are in the health facility.
•
•
•
The specimens obtained from both exposed and source should be sent to the
WGH lab STAT.
Community Nurses should refer to the laboratory guidelines on sending a STAT
specimen to the WGH lab.
Key points:
•
•
•
The requisition should clearly identify the nature of testing as a
blood and body fluid exposure incident
Send the specimens as a STAT so that rapid turnaround can be
achieved
Notify WGH lab staff of this request.
Whitehorse General Hospital
Laboratory
#5 Hospital Road
Whitehorse, Yukon
Y1A 3H7
Phone: (867) 393-8739
Chapter 2: Post Exposure Management
11
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Follow-Up Testing:
•
Clinical and laboratory follow-up should be arranged with the exposed person’s health
care provider.
•
Use the Blood and Body Fluid Exposure Form (BBFE) (Refer to Appendix J), which
outlines tests performed at baseline and to specify dates for follow up tests.
•
Complete the Exposed Person’s Follow-Up Plan (Form – Appendix K) and give it to the
client. This is the client’s summary of steps taken for initial management and any follow
up (including blood tests) that may be required.
When referring clients to YCDC for follow up:
•
Please note that YCDC obtains specimens for the following investigations with respect
to post exposure management: Anti HCV, Anti HIV, AntiHBc, HBsAg, AntiHBs
•
HCV PCR tests are ordered by a physician and are not performed at YCDC, however,
arrangements can be made through YCDC to have the testing done at the WGH lab.
•
Investigations for monitoring clients on HIV antiretroviral therapy are ordered by a
physician and are not performed at YCDC, however, arrangements can be made with
YCDC to have this testing done at the WGH lab.
Chapter 2: Post Exposure Management
12
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Table 1: Testing of the Exposed Person 
TIME SINCE
EXPOSURE
AntiHIV
Anti-HCV
HCV PCR
HBsAg 
AntiHBs

√
√
√
AntiHBc 
ASAP
√
√
3 weeks after
exposure
√
6 weeks after
exposure
√
3 months after
exposure
√
√



6 months after
exposure
√
√



√
RATIONALE FOR
TESTING OF THE
EXPOSED PERSON
To check baseline status
of the exposed person.
Negative or non-reactive
test results suggest no
prior infection.
If source is HCV+ or in a
high risk group, test
exposed person for HCV
infection by RT-PCR 
If HCV RT-PCR +, early
treatment may be
beneficial. If the exposed
person is confirmed
PCR+, active infection is
present and there is no
need to test for anti-HCV.
To check whether
seroconversion has
occurred. A change from
the initial negative (or
non-reactive) test result to
a positive (or reactive)
result indicates that
seroconversion has
occurred. Seroconversion
following a blood or body
fluid exposure does not
definitively establish that
the exposure was the
source of the virus if the
exposed person has other
risk factors.
 If the source person tests negative for HBV, HCV, and HIV and is not in a high-risk group, only
baseline testing of the exposed person is indicated.
 See Table 4, pg. 21: Hepatitis B Post-Exposure Prophylaxis
 If PCR+, a second sample needs to be tested to confirm the result.
Note: If the exposed person is a pregnant woman, request HBV testing as close to delivery as
possible.
Chapter 2: Post Exposure Management
13
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Table 2: Laboratory Collection of Specimens
Test
Anti-HIV
Hepatitis
Screening:
Anti-HCV
HBsAg
Anti-HBs
Anti-HBc
HCV PCR
Specimen
1 Yellow Top 7mL SST Tube
1 Yellow Top 7mL SST Tube
Requisition
Use BCCDC PHSA Laboratory
requisition
(Refer to Appendix H) Serology
requisition
2 pink top EDTA 7mL tubes
*Must be kept cold if transporting
from a community to Whitehorse
Use BCCDC PHSA Laboratory
requisition
(Refer to Appendix I) Virology
requisition
8. Record
•
Use the Blood and Body Fluid Exposure Form (Appendix J) to capture:
• exposed person’s risk assessment
• treatment given
• laboratory testing
• recommendations and follow up
• client copy of initial management and required follow up
•
For an occupational exposure follow WCB guidelines (not included in this
guideline) for injury reporting. This must not delay emergency assessment and
management.
Please Fax the Completed Form to:
The exposed person’s designated follow up health care provider and YCDC (if involved in
the case) Fax (867) 667-8349.
Chapter 2: Post Exposure Management
14
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
9. Follow-Up of Exposed Person
•
Encourage the exposed person to follow-up with their family physician or other
designated health practitioner as it is extremely important to discuss the results
of baseline testing and to arrange for subsequent testing. It is also necessary to
complete the hepatitis B vaccine series and/or a month of antiretroviral therapy,
if indicated.
If antiretrovirals are started, it is essential that the exposed person follow-up
with a physician as soon as possible. The antiretroviral starter kits contain only
a five day supply of medication.
•
Complete and provide the exposed person with the Exposed Person’s FollowUp Plan (form) which will act as a summary of initial management and any
required follow up.
(Refer to Appendix J: Blood and Body Fluid Exposure Form and Appendix K:
Exposed Person’s Follow-up Plan)
Follow-up of source person
•
Encourage the source person to follow-up with their health care provider.
•
If the source person is HBV negative, consider hepatitis B vaccine if indicated.
Chapter 2: Post Exposure Management
15
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
HIV EXPOSURE
____________________________________________________________________________
Table 3: Stratification of HIV Exposures
EXPOSURE RISK
EXPOSURE EXAMPLES
SIGNIFICANT RISK:
Any percutaneous exposure to infectious body
fluids 
•
Infectious body fluid
and an HIV positive
source or a known
high-risk source (Refer
to Appendix B).
•
•
Mucous membrane or non-intact skin
exposure (3 or more drops for 3 or more
minutes).
In the event of a large prolonged exposure of
blood on intact skin, assess the integrity of the
skin. If appropriate, treat as a significant risk
exposure.
RECOMMENDATION
Antiretroviral starter kit
(5 day kit)
Consult:
YCDC Weekdays
0830-1630hrs
Tel: (867) 667-8323
Medical Officer of Health:
Dr. Brendan Hanley
Tel: (867) 456-6136
Cell: (867) 332-1160
BC Centre for Excellence in
HIV/AIDS
Monday – Friday (0800 – 1700)
Tel: (604) 806-8429
Afterhours and weekends
Tel: (604) 341-1410
* Community Nurses – When using
BC-CfE consultation service, please
be advised that should HIV post
exposure prophylaxis be
recommended, this should be
discussed and prescribed by a
licensed Yukon Physician.
NEGLIGIBLE RISK:
•
Source known or
presumed to be HIV
negative
OR
•
Injury not known to
transmit HIV
OR
•
Body fluid not known
to transmit HIV
•
•
•
•
Percutaneous, mucous membrane or skin
exposure to non-infectious body fluid – source
HIV positive or negative.
Bites unless there has clearly been
transmission of infected blood.
A superficial scratch that does not bleed.
Injuries received in fights would rarely be
appropriate indications for prophylaxis unless
it is clear that transfer of infected blood has
occurred.
•
No antiretrovirals
recommended.
•
Offer counselling clarifying
the negligible risk of HIV
infection and advise re: risk
prevention (i.e. preventing
recurrences of exposure
incidents).
Antiretrovirals (ARTs) are not provided free to persons exposed to HIV as part of their personal lives (i.e. consensual adult sex, or sharing drug
injection equipment). However, the assessing physician may elect to prescribe ARTs for these situations and should consult with YCDC or the BC
Centre for Excellence in HIV/AIDS regarding which ARTs to prescribe.
Note: Prophylaxis is not recommended for needlesticks from abandoned needles when they are outside the healthcare setting or
when there is no history of the needle or the time of abandonment.
Chapter 3: HIV Exposure
16
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Antiretroviral Therapy
•
•
•
•
•
•
If antiretroviral therapy is indicated for possible HIV exposure, it should be administered
as soon as possible after exposure, preferably within 2 hours.
There is no absolute cut-off time for the initiation of antiretroviral therapy for “significant
risk” exposures (see Table 3, pg 16 for description of these types of exposures).
Antiretroviral therapy should be initiated for eligible exposed persons even if they
present more than 2 hours after the exposure.
Many exposed persons in the community do not report the incident for a day or two.
While use after 36 hours may not prevent HIV transmission, it is possible that it may
favourably alter the subsequent disease in the exposed person, with later onset of
advanced disease.
Antiretrovirals are not recommended for needlesticks from an abandoned needle
in a community setting when there is no history of the origin of the needle or the
time of its abandonment.
For Sexual Assault, HIV Risk/Post Exposure Prophylaxis refer to Appendix G.
Antiretroviral therapy will vary for:
•
•
•
•
Children (see Appendix D)
Pregnant women (see Appendix E)
Those exposed to a source known to have been on antiretroviral therapy
Source whose HIV infection is known to be drug resistant
Yukon Practitioners are encouraged to consult with the BC Centre for Excellence in
HIV/AIDS to tailor a prophylactic regimen for these individuals.
Monday – Friday (0800 – 1700) Tel: (604) 806-8429
Afterhours and weekends Tel: (604) 341-1410
Contraindications to Antiretroviral Therapy
•
•
•
•
There are many potential drug interactions with antiretroviral medication. Therefore, a
careful medication history is required before medications are prescribed.
Non-essential medications and all alternative therapy should be discontinued during
antiretroviral therapy.
Avoid or use with extreme caution in persons with chronic renal insufficiency, hepatic
insufficiency, or bone marrow dyscrasia.
Avoid or use with extreme caution in persons treated with myelosuppressive,
nephrotoxic or hepatotoxic drugs in the two weeks prior to starting antiretroviral therapy.
Chapter 3: HIV Exposure
17
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
The Antiretroviral Starter Kit
•
•
•
•
Each starter kit contains a 5-day supply of antiretroviral medications according to
current recommendations of the BC Centre for Excellence in HIV/AIDS. Drug
information sheets are included in each kit (Refer to Appendices P,Q and R for
Medication Information Sheets).
The starter kit is intended to provide 5 days of therapy while a more detailed
assessment of the risk of transmission can occur.
Within three days, follow-up should occur with the exposed person’s family
physician or designated follow up physician so that an assessment can be
made of the need for a full month of antiretroviral therapy.
Refer to Appendix O, Counselling Guidelines for Antiretroviral Therapy Initiation
Antiviral Medications
Three Drug Regimen
Dosage
Tenofovir (VIREAD)
300mg once a day
Lamivudine (3TC)
150mg bid or 300mg once a day
Kaletra (lopinavir/ritonavir) 2 tablets bid
Refer to Appendices P, Q, R for Medication Information Sheets
Pre-Treatment Laboratory Evaluation of the Exposed Person
•
No laboratory evaluation except HIV testing is required prior to initiation of the
antiretroviral therapy starter kit unless the exposed person is suspected of having
significant haematological hepatic or renal disease.
Persons continuing therapy after the starter kit should have the following laboratory
evaluation:
Interval During
Antiretroviral Therapy
Baseline
Two weeks of therapy
Required Tests
CBC and Diff, AST, ALT, Phosphorus,
Creatinine, Urinalysis
Four Weeks of therapy
Chapter 3: HIV Exposure
18
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Availability of Antiretroviral Kits
Whitehorse
•
Starter kits with a five day course of basic therapy (i.e. Tenofovir, Lamivudine,
Kaletra) antiretrovirals are available at the WGH Emergency Department and at
YCDC.
•
To obtain the remainder of the 23 day antiretroviral therapy, arrangements should
be made with YCDC by the designated follow-up physician. The medications will
then be released to the client by YCDC.
Outside of Whitehorse
•
Each Community Health Centre will have one starter kit (5 day).
•
To obtain the remainder of the 23 day antiretroviral therapy, arrangements should
be made with YCDC by the designated follow-up physician.
•
The medications will then be sent to the community by YCDC.
•
For kit replacement due to usage or drug expiry contact YCDC.
For guidelines regarding the ongoing management of those on a one month course
of antiretroviral medication, health care providers can consult the BC Centre for Excellence
in HIV/AIDS website:
http://www.cfenet.ubc.ca/our-work/initiatives/therapeutic-guidelines/accidental-exposuretherapeutic-guidelines
Chapter 3: HIV Exposure
19
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
HEPATITIS B EXPOSURE
HBV Exposure
•
A risk for HBV transmission can occur in the following situations:
• Any percutaneous, permucosal exposure (including bites), non-intact
skin exposure i.e. wound/s, dermatitis.
•
If indicated, hepatitis B immune globulin (HBIg) should be given as soon as possible
and preferably within 48 hours following the exposure.
•
If indicated, following a percutaneous exposure, HBIg should be received no later
than 7 days following the exposure.
•
If indicated, following a permucosal or sexual exposure, HBIg should be received no
later than 14 days following the exposure.
•
A person partially immunized in the past requires only the number of doses needed to
complete the recommended series, regardless of the time elapsed since the previous
dose.
•
If the source is unknown or untested (eg. a needlestick from an abandoned needle in
any community setting) offer hepatitis B vaccine (as per Table 4, pg. 21) but not HBIg.
Chapter 4: Hepatitis B Exposure
20
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Table 4: Hepatitis B Post-Exposure Prophylaxis
Vaccination
history of exposed
person
Test exposed
person for:
HBsAg, antiHBc & antiHBs.
If source is known
HBsAg positive or
high risk or
tests positive
within 48 hours of
exposure 
If source is unknown or
Not tested or
Low risk or
Tests HBsAG negative
within 48 hours of
exposure
Post-exposure
re-testing
(eg. Abandoned needle)
Documented antiHBs level (≥10 IU/L)
on prior testing
Unvaccinated
Known nonresponder to one
Hep B series
Received 1 dose of
Hep B vaccine, antiHBs status unknown
Received 2 doses of
a 3 dose Hep B
series,
anti-HBs status
unknown
Complete Hep B
vaccination (2 or 3
dose series) and
anti-HBs status
unknown or antiHBs < 10 when
tested > 6 months
post-series
Known nonresponder after
two courses of Hep
B vaccine





Test for all
three markers
for medicallegal purposes
Test for all 3
markers
Test for all 3
markers
Test for all 3
markers
Test for all 3
markers.
If anti-HBs is
<10 IU/L, then
→
Test for all 3
markers. If antiHBs is ≥ 10
U/L, then→
Test for all 3
markers.
If anti-HBs is
<10 IU/L, then
→
Test for HBsAg
& anti-HBc. Do
not test for antiHBs.
No action required.
No action required.
No action required.
Give Hepatitis B
Immune Globulin
(HBIg) and
Hepatitis B vaccine
series 
Give Hep B vaccine series
Re-test for HBsAg at 3
months & for all 3 markers at
6 months 
Give HBIg &
complete Hep B
vaccine series.
Give HBIg & 3rd
dose of Hep B
rd
vaccine. Repeat 3
dose if given too
early in series.
Do not give HBIg.
Complete Hep B
vaccine series.
Complete Hep B vaccine
series.
nd
Give 2
series
Hep B vaccine
Give 1 dose of Hep B
vaccine & retest for antiHBs in 4 wks; if <10 IU/L
repeat series.
Re-test for HBsAg at 3
months & for all 3 markers at
6 months 
Re-test for HBsAg at 3
months & for all 3 markers at
6 months 
Do not give HBIg.
Complete Hep B vaccine
series.
No re-testing required.
Give HBIg and 1
dose of vaccine.
1 dose Hep B vaccine &
retest for anti-HBs in 4wks;
if <10 IU/L complete
second series.
Re-test for HBsAg at 3
months & for all 3 markers at
6 months 
Give HBIg only &
give another dose
of HBIg in 1 mo.
No action required.
Re-test for HBsAg at 3
months & for HBsAg & antiHBc at 6 months.
A non-responder to a series of Hepatitis B vaccine is someone who demonstrates an anti-HBs level of
< 10 UI/L, when measured 1 to 6 months post-vaccination.
Consensual adult sex with known Sex Trade Worker or IDU is not an indication for HBIg, nor is a community acquired needlestick
injury: the risk of transmission is low and the number needed to treat to prevent infection is extremely high. HBIg is indicated in the
case of sexual assault or if one of the individuals is known to have acute or chronic Hepatitis B infection.
HBIg dose for all clients ≥ 8.3kg is 0.06ml/kg. Give HBIg as soon as possible, preferably within 48 hours of the exposure. For a
percutaneous exposure, HBIg may be given up to 7days following the exposure. If the client presents > 7 days following a percutaneous
exposure, give Hepatitis B vaccine only. For permucosal or sexual exposures, HBIg may be given up to 14 days following the last
exposure. If the client presents > 14 days following a permucosal or sexual exposure, give Hepatitis B vaccine only.
Hepatitis B vaccine schedule is 0, 1 and 6 months for post-exposure prophylaxis.
A second series of Hepatitis B vaccine should be offered to non-responders
Note: This table does not apply to post-exposure management of immunocompromised persons. This
group requires consultation with a physician specializing in infectious diseases.
(BC Centre for Disease Control, Blood and Body Fluid Exposure Management, March 2010, pg. 21)
Chapter 4: Hepatitis B Exposure
21
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
How to Access HBIg
Whitehorse
• With physician authorization, HBIg is requested and released from the WGH
laboratory as required.
• Administration of HBIg can be done at the WGH ER.
Whitehorse General Hospital Laboratory
#5 Hospital Road
Whitehorse, YT Y1A 3H7
Telephone: (867) 393-8739
Fax: (867) 393-8772
Regular Hours:
Monday through Friday excluding Holidays 7:00am to 11:30 am and
12:30pm to 4:00pm
After Hours:
Please call Admitting and Discharge (867) 393-8700 and ask that the on-call
laboratory personnel be paged for the release of HBIg.
Communities Outside of Whitehorse
The following Community Health Centres each have a supply of HBIg:
Beaver Creek
Ross River
Haines Junction
Dawson City
Old Crow
Mayo
Watson Lake
These seven sites have been selected as being important locations for HBIg; due to close
proximity for other health centres to access and/or due to having unique barriers i.e.
geographic, which could make the administration of this therapeutic within 48 hours
challenging.
Arrangements for the timely administration of HBIg will be made on a case by case basis
via Yukon Communicable Disease Control or the Medical Officer of Health. Should HBIg
not be stocked in the community requesting it, arrangements will be made to have it
provided from the most feasible location.
Chapter 4: Hepatitis B Exposure
22
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
HEPATITIS C EXPOSURE
While HCV is transmitted more efficiently by the parenteral route than HIV, it is transmitted by
sexual contact much less efficiently than either HBV or HIV. Transmission probabilities for
HCV are summarized in Appendix N, page 38.
At the present time, no immediate post-exposure treatment is recommended for HCV.
However, the anti-HCV status of the exposed person should be determined to assess
whether the person has been infected with HCV in the past.
Testing schedule for a person exposed to HCV:
If suspected exposure to HCV has occurred complete an anti-HCV base line test
1st Test
If anti-HCV non reactive
If anti-HCV reactive *
Complete an immediate follow-up test for HCV RNA
PCR to look for active infection
2nd Test
HCV RNA PCR performed
If HCV RNA PCR positive
Repeat PCR testing to confirm result
Follow up
Testing
3 3weeks
theinitial
initial
anti-HCV
testing,
if source’s
2weeks after
after the
anti-HCV
testing,
if source’s
HCV
status
is positive
or source
a high
HCV status
is positive
or unknown,
test is
forinHCV
RNArisk
group, perform testing for HCV RNA to look for
should be performed to look for active infection.
active infection
If HCV RNA positive;
active infection
confirmed, consult with
a health care provider
about monitoring and
treatment options
If HCV RNA negative;
active infection not
confirmed
If HCV RNA PCR negative
Repeat
anti-HCV
Repeat
anti-HCV
at: at:
months
33months
126months
months
IfIfall both
anti-HCV
tests
anti-HCV
are
negative,
tests are negative,
transmission has not
transmission has
occurred and
not occurred
monitoring
may and
monitoring
may
cease
cease
If either anti-HCV
test is positive, active
infection confirmed.
Consult with a health
care provider about
monitoring and
treatment options
*Anti-HCV takes about 5-10 weeks after infection to develop. If your baseline anti-HCV test is reactive, then you may have been infected in the
past and a follow-up HCV RNA test can be perform to determine if you are actively infected (i.e., have the virus in your blood at the present time).
Chapter 5: Hepatitis C Exposure
23
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Fluids and Tissues Capable of Transmitting Bloodborne Pathogens
FLUID
HIV
HBV
HCV
Blood and fluids visibly
contaminated with blood
Yes
Yes
Yes
Semen
Yes
Yes
Yes *
Vaginal secretions
Yes
Yes
Yes *
Pleural, amniotic,
pericardial, peritoneal,
synovial and
cerebrospinal fluids and
inflammatory exudates
Yes
Yes
Yes
No, unless
contaminated with
blood
Yes
No, unless contaminated
with blood
Transplanted tissue or
organs
Yes
Yes
Yes
Breast milk
Yes
Plausible,
particularly if
nipples are
cracked or
bleeding or if the
mother is HBeAg
positive
Plausible, particularly if
nipples are cracked or
bleeding
Saliva
Faeces
Nasal secretions
Sputum
Sweat
Tears
Urine
Vomitus
No, unless they contain visible blood.
* While HCV is transmitted more efficiently by the parenteral route than HIV, it is transmitted by sexual contact much less
efficiently than either HBV or HIV. Transmission probabilities for HCV are summarized in Appendix N, page 38.
Appendix A: Fluids and Tissues Capable of Transmitting Bloodborne Pathogens
24
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Risk Factors for Possible Transmission from the Source to the
Exposed Person
HIV
The source is a person
who has ever had:
HBV
The source is a person who
has ever had:
•
injection drug use
•
•
high-risk sexual
behaviour (i.e., multiple
sex partners, anal sex)
•
•
a sexual partner who is
an injection drug user
(IDU), or who is HIV+
•
•
•
The source is a person who has ever
had:
injection drug use and/or
inhalational drug use 
high-risk sexual behaviour
(i.e., multiple sex partners,
anal sex)
•
•
a sexual partner who is an
IDU, or who has acute or
chronic HBV 
•
a sexual partner who is an IDU, or who is
HCV+ 
blood contact with a
known case of HIV
infection
•
blood contact with a known case
of HBV infection for which there
was no provision of postexposure prophylaxis
•
blood contact with a known case of
HCV infection
emigration from a
country where HIV is
endemic
a history of multiple
transfusions of blood or
blood products prior to
Nov. 1985  OR a history
of receipt of blood-derived
coagulation products
before July 1988
•
emigration from a country
where HBV is endemic
•
a history of multiple
transfusions of blood or blood
products prior to Jan. 1972 
OR a history of receipt of bloodderived coagulation products
before January 1972
•
a history of multiple transfusions of blood
or blood products prior to May 1992  OR
a history of receipt of blood-derived
coagulation products before July 1988 or a
history of receipt of IV immunoglobulin
products prior to 1997
•
tattoo, body piercing, electrolysis,
acupuncture
a history of dialysis
•
a diagnosis of
sexually transmitted
disease(s)
•
a diagnosis of sexually
transmitted disease(s)
•
tattoo, body piercing,
electrolysis, acupuncture
a history of dialysis
•
tattoo, body piercing,
electrolysis, acupuncture
a history of dialysis
•
HCV
•
•
•
injection drug use and/or inhalational drug
use 
high-risk sexual behaviour (i.e. multiple sex
partners, anal sex)
 In Canada, testing of donated blood for anti-HIV began in November 1985; for HBsAg in January 1972; and for
anti-HCV first generation in June 1990 and anti-HCV second generation in May 1992.
 All factor concentrates distributed in Canada were heat treated after July 1988. IV immunoglobulin products
were either PCR tested for HCV or had solvent detergent virucidal treatment after 1997
 High risk examples include snorting and sniffing of cocaine and smoking crack pipes.
Appendix B: Risk Factors for Possible Transmission
25
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Window Periods
Window Periods
If the test result(s) is negative, the source person may be uninfected or may be in the
window period for laboratory detection (i.e. the period of time between exposure and
development of measurable antigen / antibodies (positive blood test).
The window period for HIV infection is most often 4 – 6 weeks. It is estimated that under
the standard testing algorithm, approximately 95% of individuals will have detectable
antibodies by 4 to 6 weeks, with >99% sero-converting by 3 months. Accordingly, 3
months is the recommended interval for HIV testing following a risk event or exposure.
The window period for HBV infection ranges from 4 weeks to 6 months.
For HCV infection, the window period ranges from 2 weeks to 6 months, but may be
longer in immunocompromised patients. In order to detect infection earlier, HCV PCR is
recommended at 3 weeks.
Appendix C: Window Periods
26
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Post-Exposure HIV Antiretroviral Therapy in Children
The risk of children being infected with HIV from accidental needle stick injuries, biting, or
sexual assault is very low. Antiretroviral agents should be considered for children where
the exposure is likely to have resulted in a transfer of potentially infectious body fluid. In
children this would most commonly occur from blood or semen from a person who is
known to be HIV+ or could potentially be HIV+.
Antiretroviral therapy will vary for children. Immediately consult BC-CfE.
BC-CfE
Monday – Friday (0800 – 1700) Tel: (604) 806-8429
Afterhours and weekends Tel: (604) 341-1410
For timely intervention, Kaletra tablets should be used until Kaletra oral solution can be
obtained.
Kaletra oral solution will be provided as soon as possible as it is
recommended by the manufacturer that the tablets not be split or crushed. Kaletra oral
solution is stored only at Whitehorse General Hospital pharmacy.
http://cfenet.ubc.ca/sites/default/files/uploads/docs/Accidental_Exposure_Therapeutic_Guideli
nes_Nov82010.pdf , pg.13
Appendix D: Post-Exposure HIV Antiretroviral Therapy in Children
27
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Post-Exposure HIV Antiretroviral Therapy in Pregnant Women
For the post-exposure HIV antiretroviral therapy of pregnant women or women who may be
pregnant, consult accordingly (BC-CfE Monday – Friday (800-1700) Tel: (604) 806-8429
Afterhours and weekends Tel: (604) 341-1410.
It should be explained to the exposed person that neither Kaletra nor Tenofovir has been
used extensively in pregnancy. Zidovudine will be provided to replace Tenofovir as soon as
possible, but if there has been a significant exposure, prophylaxis should be started with the
existing kit. Tenofovir is a pregnancy category B drug and Kaletra is a pregnancy category
C.
Appendix E: Post-Exposure HIV Antiretroviral Therapy in Pregnant Women
28
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Considerations Pertaining to Breast Feeding
HIV:
The transmission of HIV through breastfeeding is highest for women who seroconvert while
breastfeeding. Therefore, if the source is HIV positive, breastfeeding is not recommended.
Breastfeeding is also contraindicated if the mother is receiving antiretroviral
medication. If the HIV status of the source is unknown and high risk, breastfeeding should
be temporarily discontinued. During this time, the mother may pump and freeze breast milk
while awaiting source test results. If a source person has baseline HIV-negative test
results and has no recent high risk behavior, then breastfeeding can be resumed and the
frozen milk used. If a source person has baseline HIV-negative test results but has
ongoing or recent high risk behavior, then further laboratory follow-up of the source will be
required to determine if the source may have been infectious at the time of exposure.
Breastfeeding can be resumed and the frozen milk used once results of this further testing
indicate that the source was not infectious at the time of exposure.
HCV:
If a breast feeding mother is exposed to an anti-HCV+ source or a source at high risk for
HCV, she should be counselled regarding the low risk nature of HCV transmission via
breast milk, even in the setting of seroconversion. Therefore, the mother should be able to
breast feed if she desires.
HBV:
If a breastfeeding mother is exposed to a HBV positive source or an unknown source
immunize both the mother and her infant against hepatitis B, using both hepatitis B vaccine
and HBIg (depending on the infant’s age and history of HBV immunization). The mother can
then continue to breast-feed.
Appendix F: Considerations Pertaining to Breast Feeding
29
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Male and Female Sexual Assault HIV Risk/Post-Exposure
Prophylaxis (PEP) (Women’s Assault Guideline – BC Women’s Hospital and Health
Centre August 2012)
http://www.bcwomens.ca/Services/HealthServices/Sexual+Assault+Services/HealthPro
fessionals/decisionsupporttools.htm
A) Significant risk - Risk may be indicated by what is known about the source or what is known
about the setting in which the sexual assault took place:
Source:
Known HIV positive source or
Known high-risk source i.e.
Injection drug user (IDU) or men
who have sexual contact with
men (MSM)
and / or
Known or potential multiple
assailants
Setting:
Sexual assault occurs in a
setting considered high risk for
HIV
Type of
Exposure:
Non-consensual:
Plus Unknown exposure
or
Anal penetration or
Vaginal penetration
Recommendations:
HIV PEP:
Tenofovir
Lamivudine
Kaletra
Initiated within 72 hours after
sexual assault
B) Negligible Risk
Source:
Known to be negative or no
reason to believe that the source
is positive.
Setting:
Not considered high risk for HIV
OR
Type of
Exposure:
No vaginal
exposure and no
anal exposure
Recommendation:
Do not offer PEP to patients in
this category
Adequate patient counselling and
education is needed to reduce
anxiety
Oral penetration
only
C) Estimated risks of becoming infected with HIV
(Refer to Appendix N, Probability of Transmission of HIV, HBV and HCV
Appendix G: Male and Female Sexual Assault HIV Risk/Post-Exposure Prophylaxis (PEP)
30
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Appendix H BCCDC PHSA Laboratory Serology Requisition
31
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Appendix I: BCCDC PHSA Laboratory Virology Requisition
32
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Blood & Body Fluid Exposure Form
Yukon Communicable Disease Control
Inf ormation is collected under the authority of the Health Act and the Public Health Act f or purposes of providing health services and public health
services. Queries should be directed to the Manager of Yukon Communicable Disease Control, at (867) 667-8323 or toll f ree at 1-800-661-0507 ext
8323
Date Form Initiated
A. Exposed Person (recipient of exposure ) information
Name
D.O.B.
Age
Address
City/tow n
Province
Gender
M
F
HCW
YHIS #
Contact phone #
Home
Reporting person
Postal code
Work
Gen Public
In-Patient
Cell
Health care f acility
B. History of exposure
Date of exposure
Time of exposure
YYYY/MM/DD
Location of exposure
(24 hr)
C. Type of exposure (check all that apply)
Type of bodily f luid exposed to:
needlestick (specif y type & gauge)
cut by sharp object (type of instrument) specif y Instrument
Blood/serum/plasma
Bite - breaks the skin
Bodily f luid substance visibly contaminated w ith
blood (specif y)
Contact w ith exposed mucous membranes (specif y)
Contact w ith exposed non-intact skin (specif y)
(w ound < 3 days)
cut skin
Body site
chapped/abraded skin
Other bodily f luid or substance (specif y)
gloves w orn
Description of circumstances surrounding the exposure
(as provided by exposed person)
Examination of exposed person
Findings related to the exposure including assessment of injuries (e.g. depth/type of injury)
.
D. History of immunization & serostatus of exposed person
Immunization history
History
UNK
N
Y
Date
UNK
N
Date of last test
Y
Result
HBsAg
Rec'd Hep B vaccination - dose 1
Anti-HBc
Rec'd Hep B vaccination - dose 2
Anti-HBs
Rec'd Hep B vaccination - dose 3
Anti-HCV
Tetanus vaccination (date of last immunization)
Anti-HIV 1&2
E. Information on source person: risk factors and serostatus
Name
D.O.B.
Source risk f actors unknow n
Not considered high risk
High risk lif estyle or other concern f or high risk (specif y)
Age
Gender
Status
M
UNK
F
N
Y
YHIS#
Date of last blood test
HIV +
HBsAg +
YG (5674Q) F2 02/2010
Appendix J: Blood and Body Fluid Exposure Form
HCV +
33
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
F. Blood work testing of exposed & source person
(When required mark stat on requisition and notify WGH Lab)
Baseline :
EXPOSED
recommended
blood tests
____ Wk Date:
____ Wk Date:
____ Wk Date:
____ Wk Date:
____ Wk Date:
DUE
DUE
DUE
DUE
DUE
DUE
DONE
DONE
DONE
DONE
DONE
DONE
Baseline Results:
Results:
Results:
Results:
Results:
Results:
HBsAg
Anti-HBc
Anti-HBs
Anti-HIV 1&2
Anti-HCV
Indicate reason for testing on req.
(Perform 3 w eeks post-exposure w hen source is high risk)
HCV PCR
Date Draw n
Results
Source
person
SOURCE blood tests
DUE DATE
DATE DONE
Lab results to be sent to:
HBsAg
Anti-HBc
Name
Source person's follow -up Health
Care Provider:
Yukon Communicable Disease Control
Exposed
person
Anti-HBs
Anti-HCV
Anti-HIV 1&2
Exposed person's Follow -up to Health
Care Provider:
Yukon Communicable Disease Control
G. Counseling
Exposed person has been counseled as outlined in Yukon Blood & Body fluid Exposure Guidelines
yes
no (specify reason)
H. Recommendations for management of exposed person
I. Post-exposure prophylaxis of exposed person
Recommendations
Date given
Hep B vaccine
(HBV)
Dose#______
Hep B immune globulin (HBIG)
HIV post-exposure Prophylaxis
(5 day starter kit)
Consult w ith:
BCCfE
MOH
Tetanus Immunization
YCDC Other
J. Follow-up Plan:
(CLINIC)
Designated Follow -up Health Care Provider:
Phone #
FAX #
The follow ing w ill be required by Follow -up Health Care Provider:
Further post exposure counseling
(specify)
HIV 5 day starter kit has been provided. Client must be assessed w ithin
3 days. Determine need for remainder of one months supply of
antiretroviral. Consult YCDC, MOH & BC Centre for Excellence HIV/AIDS.
Hepatitis B Vaccine (HBV) - further doses of HBV
to complete 3 dose series
Follow -up blood w ork as per BBF exposure guidelines.
(0,1, 6 months) (Refer to YCDC, WHC, CHC)
- Please follow -up w ith the client for results.
- Baseline Lab results w ill be sent to you
Other:
Signature of Reporting Physician or RN
Name (printed)
Date YYYY/MM/DD
Send a copy to follow-up Health Care Provider, if YCDC is involved also fax a copy to (867) 667-8349, original to stay in Chart
Appendix J: Blood and Body Fluid Exposure Form
34
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Yukon Communicable Disease Control
Exposed Person’s Follow up Plan for Post Exposure
to Blood & Body Fluids
was seen at
Name
Date of Birth
on
location of Health Care facility
following an exposure to blood or body fluids.
Date
Initial assessment was done by
The date of exposure was
Name of initial Health Care Provider
You received the following post-exposure treatment:
Wound cleaning
Started on antiretroviral starter kit (5 days)
Tetanus Immunization
Hepatitis B Vaccine
List medications name, dose, & instructions
Hepatitis B immune globulin (HBIG)
Initial counseling f or blood and body f luid exposure
Other
You have had baseline Blood tests for:
Hepatitis B
Your follow up He alth Care Provide r is :
Hepatitis C
Location of He alth Care Facility
HIV
Phone Num be r
It is recommended that you have the following follow up:
(Check all that may apply).
Follow up is recommended for:
Location for follow -up
Date
Further doses of Hepatitis B vaccine
Hepatitis B Immune Globulin (HBIG)
You have been started on HIV antiretroviral medications. You must see your f ollow up Health
Care Provider w ithin 3 days to determine if you should continue taking the medication f or a
remaining 23 days
Results of baseline blood tests.
Follow up blood w ork
Other (specif y)
For inf ormation related to exposure of blood and body f luids and disease specif ic inf ormation please visit
http://w w w .healthlinkbc.ca/healthf iles/hf ile97.stm
If you have any questions or concerns please contact your follow up Health Care Provider or
YCDC at #4 Hospital Road Whitehorse, YT Y1A 3H8 Tel: (867) 667-8323
Appendix K: Exposed Person’s Follow up Plan
35
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Blood and Body Fluid Exposure Counselling Guidelines
Initial counselling should be done in the Emergency Department or other health facility
where post-exposure management is provided. More detailed counselling should be done
by the follow-up health care provider.
Risk of transmission to the exposed person:
•
The risk of infection after exposure to infected blood or body fluid varies by
bloodborne pathogen.
Refer to Appendix N, Probability of Transmission of HIV, HBV and HCV
If the source is not known to be HIV positive, the risk of transmission drops dramatically
and frequently the risk of prophylaxis (side effects) exceeds the risk of infection.
Evidence shows that antiretroviral therapy can reduce the risk of transmission of HIV by 86%.
The risk will vary somewhat depending on the body site of the exposure, the type of exposure,
and the source. In the instance of HIV transmission through percutaneous injury, increased
risk is associated with the following factors: greater depth of the injury, greater volume of blood
injected, visible blood on the device and/or the device previously in a source's artery or vein,
and larger gauge of needle (larger bore needles present greater risk because of the larger
volume of blood exposure). Exposures from sources with a high viral load of HIV, HBV, or
HCV (i.e. seroconversion in the acute phase of these viral infections, or in late stage AIDS) are
also associated with a greater risk of transmission.
The risks and benefits of post-exposure immunoprophylaxis or treatment should be
discussed and appropriate measures recommended to the exposed person.
Appendix L: Blood and Body Fluid Exposure Counselling Guidelines
36
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Reducing Transmission to Others
Exposed persons will be anxious and upset when initially assessed. They may not remember
all the information provided in initial counselling. It is therefore important that there is repeated
and more detailed counselling.
Physicians inexperienced in counselling of this nature should contact YCDC and enquire about
counselling resources. Information pamphlets or BC Health Files may be helpful in providing
information that the exposed person can review at home:
http://www.healthlinkbc.ca/healthfiles/hfile97.stm
If it was a significant exposure and the exposed person requires follow-up testing beyond the
baseline testing, the exposed person should be told that it may not be possible to determine for
at least 6 months whether infection has occurred. If infection has occurred, the exposed person
then is capable of transmitting infection to others. While waiting for 6 month follow-up testing to
determine if seroconversion to exposed antigens has occurred, the exposed person should be
advised to take the following precautions to prevent potential transmission of pathogens to
others:
• Abstain from sexual intercourse (vaginal, oral or rectal) or use a latex condom with a
water-based lubricant for all acts of sexual intercourse.
• Do not donate blood, plasma, organs, breast milk, tissue or sperm.
• Do not share toothbrushes, dental floss, razors, needles or other implements
that may be contaminated with blood/body fluids.
• Cover open cuts/lesions until healed.
• Put articles with blood on them (i.e. bandages, tampons, pads, tissues,
dental floss) in a separate plastic bag before disposing into household
garbage. Dispose of bloody sharp items (razors, needles, etc) into a hardsided container, taped shut. Dispose in regular garbage; do not place in
container for recycling.
• To clean up blood spills, wet surfaces with 1 part bleach to 9 parts water and leave
sitting for 10 minutes before wiping off.
• Avoid sharing needles, drug snorting equipment, etc.
• Defer a planned pregnancy; but if you become pregnant, discuss with Family
Physician.
Appendix M: Reducing Transmission to Others
37
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
PROBABILITY OF TRANSMISSION OF HIV, HBV and HCV
Table 1: Probability of Transmission HIV
Exposure (positive source)
Probability of transmission per episode
Blood transfusions (single unit of whole
blood)
90% (Donegan, 1990)
Intravenous needle or syringe exposure
0.67% (Kaplan, 1992) [1/150]
Injection drug use – needle sharing
0.67% (Kaplan, 1995) [1/150]
Needlestick
0.3% (95% CI = 0.2 to 0.5%) (Bell, 1997; Cardo, 1997) [1/333]
There have been no reported instances of transmission of HIV from improperly discarded
needles outside of the health care setting in either the USA or UK (MG Fowler, CDC, June
15, 2002 cited in Havens, 2003; Robertson, 2001). Another study found no seroconversions
in 274 community needlestick injuries in pediatrics indicating that the risk of transmission in
these events are very low (Papenburg, 2008).
Receptive anal intercourse
1 to 30% (CDC, 2005; Powers, 2008; Boily, 2009) [1/100 – 1/3]
Insertive anal intercourse
0.1 to 10% (CDC, 2005; Powers, 2008; Boily, 2009) [1/1000 – 1/10]
Receptive vaginal exposure
0.1 to 10% (CDC, 2005; Powers, 2008; Boily, 2009) [1/1000 – 1/10]
Receptive oral exposure
0.04% (Vittinghoff, 1999; PHAC, 2004) [1/2500]
Mucous membrane exposure to blood
or bodily fluids contaminated with blood
0.09% [95% CI, 0.006 to 0.5] (Ippolito, 1993; PHAC, 2004) 0.1% (ANCAHRD, 2001) [1/1000].
Human Milk Exposure (single)
0.001% - 0.004% (Havens, 2003) [1/100,000 – 1/25,000]
Table 2: Probability of HBV Transmission
Exposure (positive source)
Per episode probability of transmission
-
Sexual exposure
-
not quantified; however, receptive anal intercourse > insertive anal intercourse >
vaginal intercourse > oral-anal contact
oral-genital and oral-oral contact do not appear to be significant modes of
transmission
estimated to be transmitted 8.6 fold more efficiently than HIV
increased risk of transmission if source more infectious (i.e., higher HBV DNA &/or
HBeAg positive)
Needlestick: Source:
HBsAg positive & HBeAg positive
37-62% (Mast, 1993)
Needlestick: Source:
HBsAg positive & HBeAg negative
23-27%
Table 3: Probability of HCV Transmission
Exposure
Per episode probability of transmission
Sexual exposure
Not quantified; however:
long-term discordant monogamous partnerships are at lower risk of acquisition (0 to
0.6% per year) as compared to persons with multiple partners or those at risk for
sexually transmitted diseases (0.4 to 1.8% per year)
risk of transmission increased if source HIV co-infected
Needlestick
1.8% (range 0 to 7%) (Alter, 1997; Lanphear, 1994; Puro, 1995; Mitsui, 1992)
(Alberta MTDA PEP Protocol, January 2013, Revision, pgs 69,70)
Appendix N: Probability of Transmission of HIV, HBV, HCV
38
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Counseling Guidelines for HIV Antiretroviral Therapy
Some persons may be reluctant to take antiretroviral therapy after a seemingly minor event.
Explain that:
•
•
•
•
If HIV transmission occurs, it may lead to AIDS, which a chronic disease that may be
fatal. Drug therapy taken soon after exposure may prevent infection.
Evidence shows that antiretroviral therapy can reduce the risk of transmission of HIV by
86%.
Three drugs are used to provide increased protection and to overcome the risk of the
source virus being resistant to one drug.
Antiretroviral drugs taken for one month are considered to have few long-term side
effects despite significant morbidity in the short term, and rare mortality.
Potential Adverse Effects
Potential Adverse Effects of one Month of Antiretroviral Therapy. These estimates are based
on the experience of the Centre in the use of HIV prophylaxis and also used in the treatment
of HIV infection. In most cases, the estimates are based on the use of two drugs and the
adverse effects of three drugs may be higher.
•
•
•
•
•
Minor adverse reactions, i.e. nausea, fatigue, etc. (70% of patients).
Serious reactions, i.e. unable to work for the month of therapy (30-60% of patients).
This risk is probably lower with newer drugs.
Long term adverse effects (poorly defined) 1:5,000.
Risk of death is unknown but we would estimate that the risk of dying is 1:15,000 to
1:150,000. With three drugs without good follow-up, it may actually be higher.
With the exception of the minor adverse reactions, these risks are not based on solid
data and are provided only to guide physicians and exposed persons with crude
estimate of the hazards.
Why am I being asked to take these medications?
•
Three drugs are being used: Tenofovir, Lamivudine and Kaletra. These drugs are
commonly used together to treat patients infected with HIV. Using three drugs together
has been found to be superior to using one or two drugs. It is assumed that using three
drugs in accidental exposures will improve their effectiveness and avoid infection with
virus resistance to one drug. However this is not proven as it is impossible to test this
assumption.
Appendix O: Counseling Guidelines for HIV Antiretroviral Therapy
39
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Possible Side Effects and Contraindications of Antiretrovirals
•
Tenofovir: is well tolerated and side effects are mild. They may include nausea,
diarrhea and gas. Rarely, patients have had liver or kidney changes when taking
Tenofovir and appropriate lab testing should be done.
•
Lamivudine (3TC): Is usually well tolerated in short term therapy and side effects
are rare. Reversible decrease white blood cell count is the commonest side effect.
Tingling of the hands and feet (peripheral neuropathy) is very unlikely to occur with
one month of treatment.
•
Kaletra: Side effects include diarrhea, nausea, vomiting and abdominal pain.
Occasionally there will be changes in liver function tests. Kaletra may interact with a
wide number of medications.
Contact your Health Care Provider before taking any other type of medication or herbal
remedies.
Instructions for Taking Antiretroviral Drugs
Tenofovir: one tablet (300mg) once a day for 28 days
Lamivudine (3TC): one tablet (150mg) twice a day or (300mg) once a day for 28 days
Kaletra: two tablets twice a day with meals for 28 days
Taking all three drugs with food may reduce stomach upset.
The 5 day starter kit is intended to provide 5 days of therapy while a more detailed
assessment of the risk of transmission can occur. The exposed person should see
their follow up health care provider as soon as possible (within 3 days) after the
initiation of the starter kit to determine the need for a full 28 days of therapy.
Appendix O: Counseling Guidelines for HIV Antiretroviral Therapy
40
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Lopinavir/Ritonavir Tablet (Kaletra)
What is Kaletra®?
•
•
•
A combination of two protease inhibitors: lopinavir and ritonavir
Inhibits the replication of the HIV virus in combination with other antiretroviral agents
(ARV)
Available as a film-coated tablet containing 200 mg of lopinavir and 50 mg of ritonavir.
Why am I taking this combination of two protease inhibitors?
•
When lopinavir is combined with ritonavir, ritonavir will prevent the breakdown of
lopinavir and increase its effect. This allows the medication to be taken twice daily.
How do I take the tablet?
•
•
•
•
Usual adult dose is 2 or 3 tablets twice daily. Take only as prescribed by your physician
The medication can be taken with or without food. The tablets may be taken with food to
minimize stomach upset.
Kaletra tablets should be swallowed whole, not split, crushed or chewed.
Alcohol is not recommended in the first 4 weeks of therapy and should be used with
caution thereafter.
Take Kaletra® every day as prescribed as missing doses can lead to the
development of drug resistance. If you miss a dose, take it as soon as you
remember. If it is close to your next scheduled dose, skip the missed dose and take
your next dose at the usual time. Do not take two doses at the same time. Missed
doses (especially if just one drug in the combination) may lead to the virus becoming
resistant to all the antiretroviral drugs that you are taking, reducing or eliminating the
effect of them against the virus.
Appendix P: Lopinavir/Ritonavir Tablet (Kaletra)
41
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
What should I expect?
•
•
Side effects may include nausea, vomiting, diarrhea, loss of appetite, abdominal pain,
headaches, dry mouth, and rash. These effects usually diminish with the first month of
treatment. Contact your physician or pharmacist if any side effects occur and remain
persistent.
Redistribution or accumulation of body fat, blood cholesterol changes and/or diabetes
may occur in patients receiving antiretroviral therapy. The cause and long-term health
effects of these conditions are unknown at this time.
WARNING:
Protease inhibitors not only interact with each other, but they also can interact with
many other medications (i.e. Some anti-histamines, benzodiazepines, antituberculosis medications, analgesics, heart/blood –pressure medications, antidepressants), resulting in potentially serious and/or life threatening complications.
Always check with the pharmacist or your physician before starting any new
therapies to ensure the safety of the combination.
How do I store it?
Kaletra® film-coated tablets should be stored at room temperature (between 15 & 25
degrees C). Store all medications out of the reach of children.
Labwork to be done: Contact your Health Care Provider
If you have Questions please call:
Yukon Communicable Disease Control (YCDC)
#4 Hospital Rd
(867) 667-8323 or 1-800-661-0408 extension 8323
or Your Follow-up Health Care Provider
Adapted from BC Centre for Excellence HIV/AIDS (June 2008)
Appendix P: Lopinavir/Ritonavir Tablet (Kaletra)
42
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Lamivudine (3TC)
What is Lamivudine?
• A nucleoside analogue reverse transcriptase inhibitor used to inhibit the replication of
the HIV virus in combination with other antiretroviral agents (ARV)
• Available as 150mg tablets, 300 mg tablets and a 10 mg/mL oral solution
How do I take it?
• The usual adult dose is 150 mg twice daily or 300 mg once daily.
• Can be taken with or without food.
• Alcohol is not recommended in the first 4 weeks of therapy and should be used with
caution thereafter.
Take lamivudine every day as prescribed as missing doses can lead to the
development of drug resistance. If you miss a dose, take it as soon as you
remember. If it is close to your next scheduled dose, skip the missed dose
and take your next dose at the usual time. Do not take two doses at the same
time.
What should I expect?
• Usually well tolerated. Most common side effects are mild nausea, headache and fatigue.
• Serious side effects that have occurred in a small number of patients include allergic
reaction, pancreatitis, and elevated liver enzymes.
• Contact your doctor IMMEDIATELY, if you experience severe abdominal pain with
nausea and vomiting; these may be symptoms of an inflamed pancreas
• Inform your doctor, if you notice loss of appetite, unusual weight loss, unusual
tiredness, weakness or stomach pain
• Redistribution or accumulation of body fat, blood fat changes and/or diabetes may occur
in patients receiving antiretroviral therapy. Your doctor or pharmacist can provide you
with further information on this topic.
How do I store it?
Lamivudine should be stored in a cool, dry place at room temperature (15-30 degrees C) and
out of the reach of children.
Labwork to be done: Contact your Health Care Provider
If you have Questions please call:
Yukon Communicable Disease Control (YCDC)
#4 Hospital Road
(867) 667-8323 or 1-800-661-0408 extension 8323
or Your Follow-up Health Care Provider
Adapted from BC Centre for Excellence HIV/AIDS (June 2008)
Appendix Q: Lamivudine (3TC)
43
Blood and Body Fluid Exposure
Yukon Communicable Disease Control
4 Hospital Rd., Whitehorse, YT. Y1A 3H8
Phone: 667-8323 Fax: 667-8349
April 2013
Tenofovir (VIREAD)
What is Tenofovir?
• A nucleotide analogue used to inhibit the replication of the HIV virus in combination
with other antiretroviral agents (ARV)
• Available as a 300 mg tablet
How do I take it?
• The usual adult dose is 300 mg (1 tablet) once daily.
• Can be taken with or without food.
• Alcohol is not recommended in the first 4 weeks of therapy and should be used with
caution thereafter.
DO NOT SKIP DOSES! Missing doses can lead to the development of drug resistance
and make the virus more difficult to treat. If you miss a dose, take it as soon as you
remember. If it is close to your next scheduled dose, skip the missed dose and take
your next dose at the usual time. Do not take two doses at the same time.
What should I expect?
• Nausea, vomiting, diarrhea and gas may occur
• Rarely kidney problems may occur. Certain people (i.e. people with diabetes or high
blood pressure, elderly) may be at increased risk for developing this problem.
• Inform your doctor, if you notice loss of appetite, unusual weight loss, unusual tiredness
or weakness or stomach pain
• Redistribution or accumulation of body fat, blood fat changes and/or diabetes may occur
in patients receiving antiretroviral therapy. Your doctor or pharmacist can provide you
with further information on this topic.
How do I store it?
Tenofovir should be stored in a cool, dry place at room temperature (15-30 degrees C) out of
the reach of children.
Labwork to be done: Contact your Health Care Provider
If you have Questions please call:
Yukon Communicable Disease Control (YCDC)
#4 Hospital Road
(867) 667-8323 or 1-800-661-0408 extension 8323
or Your Follow-up Health Care Provider
Adapted from BC Centre for Excellence HIV/AIDS (June 2008)
Appendix R: Tenofovir (VIREAD)
44